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'AUTHORIZATION NO: 170 DAVIIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
P.O. Box 848.j
Mocksville, NC 27028 Subdivision Name: U�oC� V ALLcs 4�
Phone # 336-751-8760
Directions to property:r-,.) �`�L� Section: Lot:
---. AUTHORIZATION FOR
+CA -r U�-J �t-� c•-�uc�ta�-.i� i`l% WASTEWATER Tax Office PIN:# -
SYSTEM CONSTRUCTIONoad Name:
tJE/J .��V�a7��� t�J%�.4�.��y'� �Sr o,J L' UrSGC�r3 107),A L-A
ALAI14tC!l"-.,Zip: �'7C?V�
**NOTE** .This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section"prior
to issuance of any Building-Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance. ith-Artic a 11 .S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
'IS VALID FOR A PERIOD OF FIVE YEARS:
EN I M TAL HEALTH SPEA 1ST DATE SUED
1 Q DAME COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
ermittee.s �...•
Name: --11 r i i�•� �'� i 1 �: Subdivision Name: A L. L I.
Directions to property: t Fl^i "1 Ct-r- ^� �' �`` Section: 1 Lot:
i' t r .. • .4 I�l.:s' ..,� N 'f ;fin . ; c . a f v
E�IPROVEMENTPERMIT' Tax Office PIN:#
6-) rg.j Lli�ti)V�..:1G� ;t Gr14-\► ta+.�:"• F �C"{ (�,.) �i. r; �, OadNaLneA 4lY. A� Zip:
**NOTE** Ibis Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
, ,construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 f G.S. Chapter 130A; Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
.•-- �'� ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR.T 1E U41ENDED USE CHANGE. YOUR WASTEWATER
EN IR ONMENTAL HEALTH SP ALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.'
RESIDENTIAL
SPECIFICATION: BUILDING TYPE KC ( # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY v/JTYDESIGN WASTEWATER FLOW (GPD) 3100 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP_TAN� K_
GALL. RENCH WIDTH ROCK DEPTH 21-i LINEAR Fr.
OTHER `w •~f 1' _ J`,` i
I,JS'i�L� oa Lvat�,�4 '�i.yz.:;>L: �,7c �t A�_c.St�
REQUIRED SITE MODIFICATIONS/CONDITIONS: , .
1�(Z
IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLLENT FIL�ER*' #RISER(S) IF 69v e-
BELOFINISHED GRADE*
W
hu_u�JC, Wa'> sTC, 4
x ;
d .�T�:I .M
LL
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEAL
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DA!
DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
INSTALLATION. TELEPHONE # IS (704) 6340AWA X X X X X
-ei4 'ek
DAVIE COUNTY HEALTH DEPARTMENT
I U
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
1Pernittee's
Name: Subdivision Name:
• Directions to property: Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
C,A
�koad Name: 0 A Zip:--:
**NOTE** This Improvement Pem-dt DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems)
A
***NOTICE*** THIS PERM IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPF�IALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
L
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE PA k #BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
C.L
LOT S14 — TYPE WATER SUPPLY V&t3 DESIGN WASTEWAV-P, ki (GPD) j NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE
QAL. PUMP Uaa&_jGAL. TRENCH WIDTH�r ROCK DEPTH 0tl LINEAR Fr.
C -_%
GP
OTHER S
0
REQUIRED SITE MODIFICATIONS/CONDITIONS:— —Y) 0 t- L C:, Ai>
IMPROVEMENT PERMIT LAYOUTI�ISER
*APPROVED EFFLUENT 1�n &R.K. S) IF 611 BELOW FIWISH.ED GRADE*
G AC '4kj — c V4. 114
IJ r
I
"CONTACT X REPRESENTATIVE OF THE DAVIE COUNTY -REM, -DEPAkfM-ENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY INSTALLATION. TELEPHONE # IS (704) 634)9760Li x x x x yu
(33,6)751-1176
OPERATION PERMIT
SYSTEM INSTALLED BY:
76
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE ATTH&S RMED E HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I OF G.S. 5A 30A, SECTION. 1900 "SEWAGE ATMENT AN PO YSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYA=L F�gC110N SATISFACTO SFA 0 FOR ANY G OD OF TIME.
DCHD 05/96 (Revised)
NAM
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
DIRECTIONS TO SITE
PHONE NUMBER ������
SUBDIVISION NAML� 0eJ41/a/�ey
LOT A S�, A& %
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY /�� NUMBER BEDROOMS I-'_7 NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED �o INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93